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Drug Utilization Review

Drug utilization review (DUR) provides health plans with internal controls to ensure their members receive prescription drug therapy that is safe, medically necessary, and cost-effective. Our consultants develop, implement, and support DUR plans for state Medicaid plans and managed care organizations across the U.S.

We develop detailed drug reviews and conduct both prospective and retrospective prescription pattern analyses for our clients in order to:

Related Work

For patients with substance use disorders, poor medication adherence is a cause of medical complications, increased healthcare costs, and can even lead to death for some patients. Because of these risks, healthcare providers are often hesitant to prescribe medications that require high adherence to these populations.

This poster gives an overview of pulmonary exacerbation rates pre- and post-initiation of Lumacaftor/Ivacaftor (LUM/IVA) in Massachusetts' Medicaid program. Pulmonary disease is one of the leading causes of morbidity and mortality among patients with cystic fibrosis. LUM/IVA has been effective in improving pulmonary outcomes in two observational studies, but before this study, there had been no published data evaluating real-world outcomes for Medicaid patients receiving this therapy.

This poster evaluates the financial impact of high-cost infused medications across three site of care programs. Site of care programs help payers save money on specialty drug spend by shifting utilization on high costs infused medications to less costly sites of administration. The objective of this project was to evaluate the costs associated with the administration of select high-cost infused medications in site of care programs in Massachusetts Medicaid populations.

This pilot program was developed in response to a drug utilization review within a large Medicaid population that revealed some hazardous practices. Co-prescribing of opioids with benzodiazepines, gabapentin, and other stimulants occurred in more than 500 members, putting them at risk for additive central nervous system depression, misuse, abuse, and death from overdose.

Statistics show approximately 15 million Americans suffer from NASH, a nonalcoholic fatty liver disease that is projected to become the most common reason for liver transplantation. There are no FDA approved therapies for NASH, so doctors are forced to treat patients with off-label medications while keeping an eye out for breakthroughs in medication development.

We develop medication management strategies to promote appropriate opioid use while curbing abuse and misuse, and work with government groups and prescriber networks to help address this national epidemic.

Commonwealth Medicine and our business affiliate, UHealthSolutions, operate large, full-service, and clinically based call centers — ensuring that our clients are afforded all of the services they need to care for their consumers and improve health outcomes.

Medicaid agencies and managed care organizations use formularies or preferred drug lists to control pharmacy costs while maintaining quality of care. We can review and recommend drugs to include – using evidenced-based safety, efficacy, and cost information.

Prior authorization is a tool used by insurers, including public agencies like Medicaid and other health care organizations, to ensure that beneficiaries receive the most clinically appropriate and cost effective care, service, or medication. We design approaches that are evidence-based, provide efficacy and support beneficiary safety while also reducing the associated time and financial burdens.

Research on current and potential models of care and evaluation of new and existing programs is essential for states and health care organizations. Our research and evaluation services allow them to make evidence-based decisions as they develop, support, and revise health care policies.

Our team provides a range of clinically-focused solutions to health and human services agencies and organizations, helping them reach their program goals of providing the appropriate care for the populations they serve.

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